Including Subspecialists in Program Not Intent of Law, Says Board Chair

The AAFP is expressing both support and concern about a proposed CMS regulation(www.gpo.gov) that would implement a provision from the Patient Protection and Affordable Care Act to increase Medicaid payment rates to Medicare levels for primary care physicians during the next two years.

In a letter(5 page PDF) to CMS, AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, reiterates the Academy's overall support for the parity provision, saying "the AAFP was pleased that the Affordable Care Act recognized the growing crisis in Medicaid beneficiaries' access to needed primary care services and the importance of supporting primary care payments as a step toward encouraging more medical students to choose primary care specialties."

In the proposed rule, CMS says it is interested in ensuring primary care physicians receive the benefit of the increased payment, a goal shared by the AAFP, Goertz says. However, he notes, the AAFP disagrees with a part of the proposed rule that would allow subspecialists to also qualify for the increased Medicaid payment. Inclusion of subspecialists is not the intent of the law, adds Goertz, and including them would perpetuate existing disparities in physician payment rates.

Goertz points out that states will receive $11 billion in new funds in 2013-14 to increase their Medicaid payments to Medicare levels. But this funding boost is only temporary, prompting concerns from the AAFP that allowing subspecialists to qualify for the bonus will add extra costs to the program.

Story Highlights

In a letter to CMS, the AAFP expresses both support and concern about a proposed CMS regulation that would implement a Medicaid parity provision outlined in the Patient Protection and Affordable Care Act.

The AAFP supports the overall intent of the parity law itself and certain provisions of the proposed regulation.

However, the Academy disagrees with a part of the proposed regulation that would allow subspecialists to also qualify for the increased Medicaid payment.

The AAFP is urging CMS to restrict qualification for the program to physicians with a primary specialty designation of

family medicine,

general internal medicine or

pediatric medicine.

Congress did not intend for subspecialists to receive payment as primary care physicians, says Goertz, referring back to the original language in the Affordable Care Act.

"The AAFP recognizes that physician specialty alone does not necessarily define a primary care physician (because) many internal medicine and family physicians work as hospitalists or in emergency rooms. Many subspecialists also use their primary training designation in filing claims with CMS rather than their subspecialty training designation," says Goertz.

He adds that CMS should identify primary care physicians for the enhanced payment by looking for the definitional elements of primary care, which include first contact, continuity and comprehensiveness of care. However, if this should prove too difficult, Goertz suggests that CMS limit qualification for the payments to

physicians with a primary specialty designation of family medicine, general internal medicine or pediatric medicine who are board-certified in these areas or

who, if not board-certified, have at least 60 percent of their overall claims in primary care services.

In the letter, Goertz also points out that the proposed regulation calls for an update to the interim regional maximum fees physicians and other health care professionals can charge for administration of pediatric vaccines to children eligible to receive them through the Vaccines for Children (VFC) program.

CMS proposes to use the Medicare economic index to update the maximum administration fee based on the 1994 VFC value, notes Goertz. The regulation asks that states be required to compensate VFC providers at the lesser of the 2013-14 Medicare rates or the maximum regional VFC amount in those years.

"The AAFP supports this as a step in the right direction of supporting primary care physicians in their provision of this valuable public health service," Goertz says.